Mindfulness-Based Stress Reduction for Residents: A Randomized Controlled Trial

Background

Burnout is highly prevalent in residents. No randomized controlled trials have been conducted measuring the effects of Mindfulness-Based Stress Reduction (MBSR) on burnout in residents.

Objective

To determine the effectiveness of MBSR in reducing burnout in residents.

Design

A randomized controlled trial comparing MBSR with a waitlist control group.

Participants

Residents from all medical, surgical and primary care disciplines were eligible to participate. Participants were self-referred.

Intervention

The MBSR consisted of eight weekly 2.5-h sessions and one 6-h silent day.

Main Measures

The primary outcome was the emotional exhaustion subscale of the Dutch version of the Maslach Burnout Inventory–Human Service Survey. Secondary outcomes included the depersonalization and reduced personal accomplishment subscales of burnout, worry, work–home interference, mindfulness skills, self-compassion, positive mental health, empathy and medical errors. Assessment took place at baseline and post-intervention approximately 3 months later.

Key Results

Of the 148 residents participating, 138 (93%) completed the post-intervention assessment. No significant difference in emotional exhaustion was found between the two groups. However, the MBSR group reported significantly greater improvements than the control group in personal accomplishment (p?=?0.028, d?=?0.24), worry (p?=?0.036, d?=?0.23), mindfulness skills (p?=?0.010, d?=?0.33), self-compassion (p?=?0.010, d?=?0.35) and perspective-taking (empathy) (p?=?0.025, d?=?0.33). No effects were found for the other measures. Exploratory moderation analysis showed that the intervention outcome was moderated by baseline severity of emotional exhaustion; those with greater emotional exhaustion did seem to benefit.

Conclusions

The results of our primary outcome analysis did not support the effectiveness of MBSR for reducing emotional exhaustion in residents. However, residents with high baseline levels of emotional exhaustion did appear to benefit from MBSR. Furthermore, they demonstrated modest improvements in personal accomplishment, worry, mindfulness skills, self-compassion and perspective-taking. More research is needed to confirm these results.

     

Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?

Background

While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.

Objective

The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP).

Design

Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals.

Setting

A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals.

Participants

A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013.

Exposure

Admission to a hospital participating in an MSSP ACO.

Main Measures

The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA).

Key Results

For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P?=?0.89), SNF was 0.000 (P?=?0.73), IRF was 0.000 (P?=?0.96), and HHA was 0.001 (P?=?0.57)). Payments reduced significantly for PAC overall (??$130.41, P?=?0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant.

Conclusions

Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.

     

Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial

Background

Early in medical education, physicians must develop competencies needed for tobacco dependence treatment.

Objective

To assess the effect of a multi-modal tobacco dependence treatment curriculum on medical students’ counseling skills.

Design

A group-randomized controlled trial (2010–2014) included ten U.S. medical schools that were randomized to receive either multi-modal tobacco treatment education (MME) or traditional tobacco treatment education (TE).

Setting/Participants

Students from the classes of 2012 and 2014 at ten medical schools participated. Students from the class of 2012 (N?=?1345) completed objective structured clinical examinations (OSCEs), and 50 % (N?=?660) were randomly selected for pre-intervention evaluation. A total of 72.9 % of eligible students (N?=?1096) from the class of 2014 completed an OSCE and 69.7 % (N?=?1047) completed pre and post surveys.

Interventions

The MME included a Web-based course, a role-play classroom demonstration, and a clerkship booster session. Clerkship preceptors in MME schools participated in an academic detailing module and were encouraged to be role models for third-year students.

Measurements

The primary outcome was student tobacco treatment skills using the 5As measured by an objective structured clinical examination (OSCE) scored on a 33-item behavior checklist. Secondary outcomes were student self-reported skills for performing 5As and pharmacotherapy counseling.

Results

Although the difference was not statistically significant, MME students completed more tobacco counseling behaviors on the OSCE checklist (mean 8.7 [SE 0.6] vs. mean?8.0 [SE 0.6], p?=?0.52) than TE students. Several of the individual Assist and Arrange items were significantly more likely to have been completed by MME students, including suggesting behavioral strategies (11.8 % vs. 4.5 %, p?<?0.001) and providing information regarding quitline (21.0 % vs. 3.8 %, p?<?0.001). MME students reported higher self-efficacy for Assist, Arrange, and Pharmacotherapy counseling items (ps?≤0.05).

Limitations

Inclusion of only ten schools limits generalizability.

Conclusions

Subsequent interventions should incorporate lessons learned from this first randomized controlled trial of a multi-modal longitudinal tobacco treatment curriculum in multiple U.S. medical schools.NIH Trial Registry Number: NCT01905618

     

Patient–Family Agenda Setting for Primary Care Patients with Cognitive Impairment: the SAME Page Trial

Background

Establishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.

Objective

To examine whether a patient–family agenda setting intervention improves primary care visit communication for patients with cognitive impairment

Design

Two-group pilot randomized controlled study

Participants

Patients aged 65?+ with cognitive impairment and family companions (n?=?93 dyads) and clinicians (n?=?14) from two general and one geriatrics primary care clinic

Intervention

A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda

Measurements

Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion

Results

Dyads were randomized to usual care (n?=?44) or intervention (n?=?49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p?=?0.012) and mood (42.9 versus 24.5%; p?=?0.013) whereas companions more often identified safety (36.7 versus 18.4%; p?=?0.039) and personality/behavior change (32.7 versus 16.3%; p?=?0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p?<?0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p?=?0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p?<?0.001) and less biomedical talk (p?<?0.001) and companions were more verbally active (p?<?0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.

Conclusion

Patient–family agenda setting may improve primary care visit communication for patients with cognitive impairment.

Trial Registration

ClinicalTrials.gov: NCT02986958

     

Double-catheter lavage combined with percutaneous flexible endoscopic debridement for infected pancreatic necrosis failed to percutaneous catheter drainage

Background

Infected pancreatic necrosis (IPN) is a serious local complication of acute pancreatitis, with high mortality. Minimally invasive therapy including percutaneous catheter drainage (PCD) has become the preferred method for IPN instead of traditional open necrosectomy. However, the efficacy of double-catheter lavage in combination with percutaneous flexible endoscopic debridement after PCD failure is unknown compared with surgical necrosectomy.

Methods

A total of 27 cases of IPN patients with failure PCD between Jan 2014 and Dec 2015 were enrolled in this retrospective cohort study. Fifteen patients received double-catheter lavage in combination with percutaneous flexible endoscopic debridement, and 12 patients underwent open necrosectomy. The primary endpoint was the composite end point of major complications or death. The secondary endpoint included mortality, major complication rate, ICU admission length of stay, and overall length of stay.

Results

The primary endpoint occurrence rate in double-catheter lavage in combination with percutaneous flexible endoscopic debridement group (8/15, 53%) was significantly lower than that in open necrosectomy group (11/12, 92%) (RR?=?1.71, 95% CI?=?1.04 – 2.84, P?<?0.05). Though the mortality between two groups showed no statistical significance (0% vs. 17%, P?=?0.19), the rate of new-onset multiple organ failure and ICU admission length of stay in the experimental group was significantly lower than that in open necrosectomy group (13% vs. 58%, P?=?0.04; 0 vs. 17, P?=?0.02, respectively). Only 40% of patients required ICU admission after percutaneous debridement, which was markedly lower than the patients who underwent surgery (83%; P?<?0.05).

Conclusions

Double-catheter lavage in combination with percutaneous flexible endoscopic debridement showed superior effectiveness, safety, and convenience in patients with IPN after PCD failure as compared to open necrosectomy.

     

Statin Use,Diabetes Incidence and Overall Mortality in Normoglycemic and Impaired Fasting Glucose Patients

BACKGROUND

The association between the use of statins and the risk of diabetes and increased mortality within the same population has been a source of controversy, and may underestimate the value of statins for patients at risk.

OBJECTIVE

We aimed to assess whether statin use increases the risk of developing diabetes or affects overall mortality among normoglycemic patients and patients with impaired fasting glucose (IFG).

DESIGN AND PARTICIPANTS

Observational cohort study of 13,508 normoglycemic patients (n?=?4460; 33 % taking statins) and 4563 IFG patients (n?=?1865; 41 % taking statin) among residents of Olmsted County, Minnesota, with clinical data in the Mayo Clinic electronic medical record and at least one outpatient fasting glucose test between 1999 and 2004. Demographics, vital signs, tobacco use, laboratory results, medications and comorbidities were obtained by electronic search for the period 1999–2004. Results were analyzed by Cox proportional hazards models, and the risk of incident diabetes and mortality were analyzed by survival curves using the Kaplan–Meier method.

MAIN MEASURES

The main endpoints were new clinical diagnosis of diabetes mellitus and total mortality.

KEY RESULTS

After a mean of 6 years of follow-up, statin use was found to be associated with an increased risk of incident diabetes in the normoglycemic (HR 1.19; 95 % CI, 1.05 to 1.35; p?=?0.007) and IFG groups (HR 1.24; 95%CI, 1.11 to 1.38; p?=?0.0001). At the same time, overall mortality decreased in both normoglycemic (HR 0.70; 95 % CI, 0.66 to 0.80; p?<?0.0001) and IFG patients (HR 0.77, 95 % CI, 0.64 to 0.91; p?=?0.0029) with statin use.

CONCLUSION

In general, recommendations for statin use should not be affected by concerns over an increased risk of developing diabetes, since the benefit of reduced mortality clearly outweighs this small (19–24 %) risk.

     

Does laparoscopic intracorporeal ileocolic anastomosis decreases surgical site infection rate? A propensity score-matched cohort study

Aim

Foreshortened mesentery or thick abdominal wall constitutes a rationale for laparoscopic intracorporeal ileocolic anastomoses (ICA). The aim of this study was to compare intracorporeal to extracorporeal ICA in terms of surgical site infections in patients with Crohn’s ileitis and overweight patients with right colon tumors.

Method

This was a prospective propensity score-matched cohort study enrolling consecutive patients with Crohn’s terminal ileitis and overweight patients with right colon tumors undergoing elective laparoscopic right colon resection with intracorporeal or extracorporeal ICA. Propensity score matching with a 1:1 ratio was employed to compare diagnosis-matched patients for age, BMI, ASA, and previous abdominal surgery.

Results

Overall, 453 patients were enrolled: 233 intracorporeal vs. 220 extracorporeal. Propensity score matching left 195 intracorporeal and 195 extracorporeal patients comparable for age (p?=?0.294), gender (p?=?0.683), ASA (p?=?0.545), BMI (p?=?0.079), previous abdominal surgery (p?=?0.348), and diagnosis (p?=?0.301). Conversion rates (5.1 vs. 3.6%; p?=?0.457) and intraoperative complications (1 vs. 2.1%; p?=?0.45) were similar. Overall morbidity (5.1 vs. 12.8%; p?=?0.008) and re-intervention rates (3.1 vs. 8.7%; p?=?0.029) were significantly higher in extracorporeal patients. Anastomotic leak rates (0.5 vs. 1.5%; p?=?0.623) did not differ. Incisional SSI rate was significantly higher in extracorporeal patients (p?=?0.01).

Conclusion

Laparoscopic intracorporeal ICA reduced incisional SSI rates as compared to its extracorporeal counterpart.

     

An Electronic Adherence Measurement Intervention to Reduce Clinical Inertia in the Treatment of Uncontrolled Hypertension: The MATCH Cluster Randomized Clinical Trial

BACKGROUND

To appropriately manage uncontrolled hypertension, clinicians must decide whether blood pressure (BP) is above goal due to a need for additional medication or to medication nonadherence. Yet, clinicians are poor judges of adherence, and uncertainty about adherence may promote inertia with respect to medication modification.

OBJECTIVE

We aimed to determine the effect of sharing electronically-measured adherence data with clinicians on the management of uncontrolled hypertension.

DESIGN

This was a cluster randomized trial.

PARTICIPANTS

Twenty-four primary care providers (12 intervention, 12 usual care; cluster units) and 100 patients with uncontrolled hypertension (65 intervention, 35 usual care) were included in the study.

INTERVENTIONS

At one visit per patient, clinicians in the intervention group received a report summarizing electronically measured adherence to the BP regimen and recommended clinical actions. Clinicians in the control group did not receive a report.

MAIN MEASURES

The primary outcome was the proportion of visits with appropriate clinical management (i.e., treatment intensification among adherent patients and adherence counseling among nonadherent patients). Secondary outcomes included patient-rated quality of care and communication during the visit.

KEY RESULTS

The proportion of visits with appropriate clinical management was higher in the intervention group than the control group (45 out of 65; 69 %) versus (12 out of 35; 34 %; p?=?0.001). A higher proportion of adherent patients in the intervention group had their regimen intensified (p?=?0.01), and a higher proportion of nonadherent patients in the intervention group received adherence counseling (p?=?0.005). Patients in the intervention group were more likely to give their clinician high ratings on quality of care (p?=?0.05), and on measures of patient-centered (p?=?0.001) and collaborative communication (p?=?0.02).

CONCLUSIONS

Providing clinicians with electronically-measured antihypertensive adherence reports reduces inertia in the management of uncontrolled hypertension.

Trial Registration

NCT01257347; http://clinicaltrials.gov/show/NCT01257347

     

Collaborative Hypertension Case Management by Registered Nurses and Clinical Pharmacy Specialists within the Patient Aligned Care Teams (PACT) Model

BACKGROUND

Clinical Pharmacy Specialists (CPSs) and Registered Nurses (RNs) are integrally involved in the Patient Aligned Care Teams (PACT) model, especially as physician extenders in the management of chronic disease states. CPSs may be an alternative to physicians as a supporting prescriber for RN case management (RNCM) of poorly controlled hypertension.

OBJECTIVE

To compare CPS-directed versus physician-directed RNCM for patients with poorly controlled hypertension.

DESIGN

Non-randomized, retrospective comparison of a natural experiment.

SETTING

A large Midwestern Veterans Affairs (VA) medical center.

INTERVENTION

Utilizing CPSs as alternatives to physicians for directing RNCM of poorly controlled hypertension.

PATIENTS

All 126 patients attended RNCM appointments for poorly controlled hypertension between 20 September 2011 and 31 October 2011 with either CPS or physician involvement in the clinical decision making. Patients were excluded if both a CPS and a physician were involved in the index visit, or they were enrolled in Home Based Primary Care, or if they displayed non-adherence to the plan.

MAIN MEASURES

All data were obtained from review of electronic medical records. Outcomes included whether a patient received medication intensification at the index visit, and as the main measure, blood pressures between the index and next consecutive visit.

KEY RESULTS

All patients had medication intensification. Patients receiving CPS-directed RNCM had greater decreases in systolic blood pressure compared to those receiving physician-directed RNCM (14?±?13 mmHg versus 10?±?11 mmHg; p?=?0.04). After adjusting for the time between visits, initial systolic blood pressure, and prior stroke, provider type was no longer significant (p?=?0.24). Change in diastolic blood pressure and attainment of blood pressure < 140/90 mm Hg were similar between groups (p?=?0.93, p?=?0.91, respectively).

Conclusions

CPS-directed and physician-directed RNCM for hypertension demonstrated similar blood pressure reduction. These results support the utilization of CPSs as prescribers to support RNCM for chronic diseases.

     

Neutrophil-to-Lymphocyte Ratio Predicts Outcome in Limited Disease Small-cell Lung Cancer

Introduction

Patients with limited disease small-cell lung cancer (SCLC) receive radiochemotherapy followed by prophylactic cranial irradiation. The prognosis of these patients remains poor with a median survival of 16–24 months. Systemic inflammation was suggested as an important prognostic factor for outcomes. This study investigated the impact of systemic inflammation measured with neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) at first diagnosis in patients with limited disease SCLC for outcomes.

Methods

Data of 65 patients receiving radiochemotherapy for limited disease SCLC were analyzed. NLR and PLR were obtained from blood sample at first diagnosis of SCLC and 12 characteristics including gender, age, ECOG, T-category, N-category, pack years, smoking during radiotherapy, respiratory insufficiency, hemoglobin levels during radiotherapy, radiation dose (<56 vs. ≥56 Gy), concurrent radiochemotherapy, and prophylactic cranial irradiation (PCI) were evaluated for local control, metastasis-free survival, and overall survival.

Results

Survival rates at 1, 2, and 3 years were 71, 45, and 28%, respectively. Median survival time was 20 months. Independent factors for improved survival were NLR?<?4 (p?=?0.03), ECOG 0–1 (p?=?0.002), and PCI (p?=?0.015). Lower T-category was an independent positive factor of local control (p?=?0.035). Improved metastasis-free survival was associated with NLR?<?4 (p?=?0.011), ECOG 0–1 (p?=?0.002), N-category 0–1 (p?=?0.048), non-smoking during radiotherapy (p?=?0.009), and PCI (p?=?0.006).

Conclusion

NLR was found to be an independent prognostic factor for overall survival. The evaluation of NLR can help identify patients with poor prognosis and appears a useful prognostic marker in clinical practice. A prospective analysis is warranted to confirm these findings.

     

Lymphoid hyperplasia of the colon and its association with underlying allergic airway diseases

Purpose

The purpose of this study was to determine the prevalence of lymphoid hyperplasia in the lower gastrointestinal tract and its role in patients undergoing colonoscopic examinations, particularly focusing on any allergic predisposition.

Methods

A database search performed at the Department of Gastroenterology at Onomichi Municipal Hospital identified seven patients with lymphoid hyperplasia in the large intestine (i.e., cecum, colon, and/or rectum). Data regarding the endoscopic, biological, and pathological examinations performed and the allergic histories for each patient were retrospectively reviewed from the clinical records.

Results

Median age of the patients (four males, three females) was 50 years. Lymphoid hyperplasia was seen in the cecum (n?=?5), ascending colon (n?=?2), and transverse colon (n?=?1). Six patients (85.7 %) had one of the allergic airway diseases: allergic rhinoconjunctivitis for pollen (n?=?3), bronchial asthma (n?=?1), infantile asthma (n?=?1), or allergic bronchitis (n?=?1). Drug allergy (n?=?3) and urticaria (n?=?2) were also found. All seven patients had one or more allergic diseases; however, none had a history of food allergy. Blood tests for allergens revealed that six patients (85.7 %) had positive reactions to inherent allergens, whereas only one patient had a positive reaction to food allergens.

Conclusions

Our results indicate that lymphoid hyperplasia in the large intestine may be associated with allergic airway diseases rather than with food allergies; thus, its presence may be useful to detect patients with underlying airway hyperreactivity.

     

Pneumothorax in Patients with Pulmonary Langerhans Cell Histiocytosis

Introduction

Pneumothorax often develops in pulmonary Langerhans cell histiocytosis (PLCH), but some patients take a long time to be correctly diagnosed.

Objectives

This study assessed the frequency of pneumothorax in PLCH and analysed the role of chest computed tomography (CT) in the prompt diagnosis.

Patients and material

Of the 90 patients with PLCH seen from 2000 to 2015, 29 (32%) had pneumothorax as the initial finding. In this group, 18 (62%) patients were diagnosed within 1 month, whereas the diagnosis was delayed for 4–120 months in 11 (38%) patients.

Results

Patients who had pneumothorax as the initial sign of PLCH tended to be younger (mean age 27.7?±?7.92 vs. 39.9?±?13.21 years; P?=?0.0001), male (69% vs. 43%; P?=?0.028), smoked less (mean pack/years 8.4?±?6.85 vs. 19?±?17.16; P?=?0.003), and had a significantly lower mean FVC (77.96?±?19.62 vs. 89.47?±?21.86% pred.; P?=?0.015) and FEV₁ (68.6?±?19.93 vs. 79.4?±?21.48% pred.; P?=?0.03 than patients who had no pneumothorax. Recurrent pneumothorax was diagnosed more frequently in the group with a delayed diagnosis (82% vs. 39%; P?=?0.02). CT was performed in all of the patients who were diagnosed promptly, but in none of the patients with a delayed diagnosis.

Conclusions

Patients who had pneumothorax as the initial sign of PLCH were younger, more frequently men, and had greater respiratory impairment than those who had no pneumothorax. CT in patients with pneumothorax led to a correct diagnosis of this disease.

     

Braun anastomosis lowers the incidence of delayed gastric emptying following pancreaticoduodenectomy: a meta-analysis

Background

Delayed gastric emptying (DGE) is one of the most frequent complications following pancreaticoduodenectomy. This meta-analysis aimed to evaluate the impact of Braun enteroenterostomy on DGE following pancreaticoduodenectomy.

Methods

A systematic review of the literature was performed to identify relevant studies. Statistical analysis was carried out using Review Manager software 5.3.

Results

Eleven studies involving 1672 patients (1005 in Braun group and 667 in non-Braun group) were included in the meta-analysis. Braun enteroenterostomy was associated with a statistically significant reduction in overall DGE (odds ratios [OR] 0.32, 95% confidence intervals [CI] 0.24 to 0.43; P <0.001), clinically significant DGE (OR 0.27, 95% CI 0.15 to 0.51; P <0.001), bile leak (OR 0.50, 95% CI 0.29 to 0.86; P?=?0.01), and length of hospital stay (weighted mean difference -1.66, 95% CI -2.95 to 00.37; P?=?0.01).

Conclusions

Braun enteroenterostomy minimizes the rate and severity of DGE following pancreaticoduodenectomy.

     

Neuromuscular comorbidity,heart failure,and atrial fibrillation as prognostic factors in left ventricular hypertrabeculation/noncompaction

Background

There is some controversy concerning the prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT). LVHT is frequently associated with neuromuscular disorders (NMDs). The aim of this study was to assess cardiac and neurological findings as predictors of mortality in patients with LVHT.

Patients and methods

The study included patients with LVHT diagnosed between June 1995 and January 2014 in one echocardiographic laboratory. They underwent a baseline cardiologic examination and were invited for a neurological examination. Between January and February 2014, their survival status was assessed.

Results

LVHT was diagnosed in 220 patients (68 female, aged 52?±?17 years) with a prevalence of 0.35?%/year. During a follow-up of 72?±?61 months, 65 patients died. The mortality was 5?%/year. A neurological investigation was performed on 173 patients (79?%) and revealed specific NMDs in 31 (14?%), NMD of unknown etiology in 103 (47?%), and normal findings in 39 (18?%) patients. In multivariate analysis, the predictors of mortality were increased age (p?=?0.0001), presence of a specific NMD (p?=?0.0062) or NMD of unknown etiology (p?=?0.0062), heart failure NYHA III (p?=?0.0396), atrial fibrillation (p?=?0.0022), and sinus tachycardia (p?=?0.0395).

Conclusions

LVHT patients should undergo systematic neurological examinations. Whether an optimal therapy of heart failure and atrial fibrillation will improve the prognosis of LVHT patients needs to be addressed in further studies.

     

Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study

Background

Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized.

Objective

To identify the association between insurance coverage and mortality of patients transferred between hospitals.

Design

We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers.

Setting

Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers.

Patients

The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals.

Measurements

Adjusted inpatient mortality and 24-h mortality, stratified by insurance status.

Results

Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p?=?0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p?=?0.026), and earlier in their hospital course (3.9 vs 2.0 days, p?=?0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13–1.36, p?<?0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11–1.60, p?<?0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses.

Limitations

This is an observational study where transfer appropriateness cannot be directly assessed.

Conclusions

Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.

     

Malignancy is a risk factor for postoperative infectious complications after elective colorectal resection

Purpose

Patient and technical factors influencing the postoperative infectious complications (ICs) after elective colorectal resections are satisfactorily described. However, the underlying disease-related factors have not been extensively evaluated. This study aimed to measure the effect of malignancy on postoperative surgical site and extra surgical site infections after elective colorectal resection.

Methods

This study is a bicentric retrospective matched pair study of prospectively gathered data. Between 2004 and 2013, 1104 consecutive patients underwent colorectal resection in two centers. Patients undergoing elective resection with supraperitoneal anastomosis for benign diseases (excluding inflammatory bowel disease) (group B, n?=?305) were matched to randomly selected patients with malignancy (group M, n?=?305). The matching variables were age, gender, American Society of Anesthesiologists (ASA) score, malnutrition, type of resection, and surgical approach. We compared the 30-day IC rates between patients with benign diseases (group B) and malignancy (group M). Multivariate logistic regression analysis was performed to identify the risk factors for ICs.

Results

Group M had a higher overall rate of IC (25.6 vs 16.1 %, P?=?0.004) as well as a higher risk of extra surgical site infections (P?=?0.007) and anastomotic leakage (P?=?0.039). The independent risk factors for ICs were malignancy (odds ratio (OR)?=?2.02; P?=?0.002), age ≥70 years (OR?=?1.73, P?=?0.018), tobacco history (OR?=?1.87; P?=?0.030), and obesity (OR?=?1.68; P?=?0.039).

Conclusion

Malignancy, age, tobacco history, and obesity increase the risk of ICs after colorectal resection. Improvement of the modifiable risk factors, increased compliance with an enhanced recovery after surgery (ERAS) program in the overall population, and optimization of immune function in patients with malignancy should be considered.

     

Communication Skills Training for Physicians Improves Patient Satisfaction

BACKGROUND

Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted.

OBJECTIVE

We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience.

DESIGN

This was an observational study.

SETTING

The study was conducted at a large, multispecialty academic medical center.

PARTICIPANTS

Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014.

INTERVENTION

An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationship-centered model.

MAIN MEASURES

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction.

KEY RESULTS

Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p?<?0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p?=?0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p?=?0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4?±?12.7 vs. 124?±?11.9, p?<?0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months.

CONCLUSIONS

System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.

     

Expression of α-Defensins,CD20+ B-lymphocytes,and Intraepithelial CD3+ T-lymphocytes in the Intestinal Mucosa of Patients with Liver Cirrhosis: Emerging Mediators of Intestinal Barrier Function

Aim

The present study investigates the role of innate and adaptive immune system of intestinal mucosal barrier function in cirrhosis.

Methods

Forty patients with decompensated (n?=?40, group A), 27 with compensated cirrhosis (n?=?27, group B), and 27 controls (n?=?27, group C) were subjected to duodenal biopsy. Expression of α-defensins 5 and 6 at the intestinal crypts was evaluated by immunohistochemistry and immunofluorescence. Serum endotoxin, intestinal T-intraepithelial, and lamina propria B-lymphocytes were quantified.

Results

Cirrhotic patients presented higher endotoxin concentrations (p?<?0.0001) and diminished HD5 and HD6 expression compared to healthy controls (p?=?0.000287, p?=?0.000314, respectively). The diminished HD5 and HD6 expressions were also apparent among the decompensated patients compared to compensated group (p?=?0.025, p?=?0.041, respectively). HD5 and HD6 expressions were correlated with endotoxin levels (r?=?-0.790, p?<?0.0001, r?=???0.777, p?<?0.0001, respectively). Although intraepithelial T-lymphocytes were decreased in group A compared to group C (p?=?0.002), no notable alterations between groups B and C were observed. The B-lymphocytic infiltrate did not differ among the investigated groups.

Conclusions

These data demonstrate that decreased expression of antimicrobial peptides may be considered as a potential pathophysiological mechanism of intestinal barrier dysfunction in liver cirrhosis, while remodeling of gut-associated lymphoid tissue as an acquired immune response to bio-pathogens remains an open field to illuminate.

     

Beta-Blockers and ACE Inhibitors Are Associated with Improved Survival Secondary to Ventricular Tachyarrhythmia

Objective

The study sought to assess the impact of treatment with beta-blocker (BB) or ACE inhibitor/angiotensin receptor blocker (ACEi/ARB) on secondary survival in patients presenting with ventricular tachyarrhythmia.

Background

Data regarding outcome of patients presenting with ventricular tachyarrhythmia treated with BB and ACEi/ARB is limited.

Methods

A large retrospective registry was used including consecutive patients presenting with ventricular tachycardia and fibrillation from 2002 to 2016 on admission. Applying propensity-score matching for harmonization, the impact of “BB” and “ACEi/ARB” was comparatively evaluated. The primary prognostic outcome was long-term all-cause death at 3 years.

Results

A total of 972 matched patients were included. Both patients with BB (long-term mortality rate 18 versus 27%; log rank p?=?0.041; HR?=?0.661; 95% CI?=?0.443–0.986; p?=?0.043) and with ACEi/ARB (long-term mortality rate 13 versus 23%; log rank p?=?0.004; HR?=?0.544; 95% CI?=?0.359–0.824; p?=?0.004) revealed better secondary survival compared to patients without after presenting with ventricular tachyarrhythmia on admission. The prognostic benefit of BB was comparable to ACEi/ARB (long-term mortality rate 21 versus 26%; log rank p?=?0.539).

Conclusion

BB and ACEi/ARB were associated with improved secondary survival in patients surviving ventricular tachyarrhythmia on admission.

Trial Registration

ClinicalTrials.gov identifier: NCT02982473